Nursing Diagnosis: Decreased Cardiac Output related to altered myocardial contractility, inotropic changes, alterations in rate, rhythm, electrical conduction, structural changes, such as valvular defects and ventricular aneurysm
Possibly evidenced by
Increased heart rate (tachycardia), dysrhythmias, ECG changes
Changes in BP (hypotension, hypertension)
Extra heart sounds (S3, S4)
Decreased urine output
Diminished peripheral pulses
Cool, ashen skin and diaphoresis
Orthopnea, crackles, JVD, liver engorgement, edema
Desired Outcomes/Evaluation Criteria—Client Will
Cardiac Pump Effectiveness
Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example,
hemodynamic parameters within acceptable limits and urinary output adequate.
Report decreased episodes of dyspnea and angina.
Cardiac Disease Self-Management
Participate in activities that reduce cardiac workload.
Nursing Care Plan Intervention with Rationale:
1. Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available.
Rationale: Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive
to medication suggest ventricular aneurysm.
2. Note heart sounds.
Rationale: S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant, distended chambers.
Murmurs may reflect valvular incompetence and stenosis.
3. Palpate peripheral pulses.
Rationale: Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans may be present.
4. Monitor BP.
Rationale: In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound or irreversible hypotension may occur. Note: Many clients with HF have consistently low systolic BP (80 to 100 mm Hg) due to their disease process and the medications they take, and most
tolerate these BPs without incident (Wingate, 2007).
5. Inspect skin for pallor and cyanosis.
Rationale: Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.
6. Monitor urine output, noting decreasing output and dark or concentrated urine.
Rationale: Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues, but may be
increased at night because fluid returns to circulation when client is recumbent.
7. Note changes in sensorium, for example, lethargy, confusion, disorientation, anxiety, and depression.
Rationale: May indicate inadequate cerebral perfusion secondary to decreased cardiac output.
8. Encourage rest, semirecumbent in bed or chair. Assist with physical care, as indicated.
Rationale: Physical rest should be maintained during acute or refractory HF to improve efficiency of cardiac contraction and to decrease myocardial oxygen consumption and workload.
9. Provide quiet environment, explain medical and nursing management, help client avoid stressful situations, listen and respond to expressions of feelings or fears.
Rationale: Physical and psychological rest helps reduce stress, which can produce vasoconstriction, elevating BP and increasing heart rate and work.
10. Provide bedside commode. Have client avoid activities eliciting a vasovagal response, for instance, straining during defecation and holding breath during position changes.
Rationale: Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function and output.
11. Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase ambulation and activity as tolerated.
Rationale: Decreases venous stasis and may reduce incidence of thrombus and embolus formation.
12. Check for calf tenderness; diminished pedal pulse; and swelling, local redness, or pallor of extremity.
Rationale: Reduced cardiac output, venous pooling and stasis, and enforced bedrest increases risk of thrombophlebitis.
13. Withhold digoxin, as indicated, and notify physician if marked changes occur in cardiac rate or rhythm or signs of digoxin toxicity occur.
Rationale: Incidence of toxicity is high (20%) because of narrow margin between therapeutic and toxic ranges. Digoxin may have to be discontinued in the presence of toxic drug levels, a slow
heart rate, or low potassium level.